Extended Deep PlaneFaceliftIncorporating Facial Retaining LigamentRelease and Composite Flap Shifts toMaximize Midface, Jawline and NeckRejuvenation

Andrew Jacono, MDa,b,*, Lucas M. Bryant, MDa

INTRODUCTION

To better understand the rationale behind deepplane facelifting and how it differs from lateral su-perficial muscular aponeurotic system (SMAS)facelifting (high or low), an understanding of thecomplex anatomy of the SMAS and soft tissuesof the face is necessary. The SMAS layer was firstdescribed by Mitz and Peyronie in 1976.1 TheSMAS layer is continuous with the platysma mus-cle inferiorly and the temporoparietal fascia andgalea aponeurotica superiorly. In the face, theSMAS lies between the subcutaneous adipose

tissue, which compromises the superficial fatcompartments of the face, and the underlyingparotidomasseteric fascia, within which lies thefacial nerves. The thickest SMAS is found in thelateral face overlying the parotid gland. TheSMAS attenuates as it travels from lateral tomedial in the midface, terminating at the lateralborder of the zygomaticus major muscle2 (Fig. 1).

Sub-SMAS dissection techniques, first intro-duced by Skoog in 1974,3 tend to allow for bothimprovement of aesthetic change as well asincreased longevity. The variance of SMASmobility in different facial regions is important

Disclosure: The authors have nothing to disclose.a NewYork Center for Facial Plastic and Laser Surgery, 630 Park Avenue, NewYork, NY 10065, USA; b Departmentof Otolaryngology/Head and Neck Surgery, Albert Einstein College of Medicine, 1300 Morris Park Avenue,Bronx, NY 10461, USA* Corresponding author. New York Center for Facial Plastic and Laser Surgery, 630 Park Avenue, New York, NY10065.E-mail address: drjacono@gmail.com

KEYWORDS

� Rhytidectomy � Face lift � Deep plane facelift � Facial retaining ligaments � SMAS � Platysma� Neck lift

KEY POINTS

� Deep plane facelifting targets the mobile medial superficial muscular aponeurotic system, bypass-ing the lateral fixed superficial muscular aponeurotic system dissected in these techniques.

� Releasing facial and cervical retaining ligaments allows greater redraping of the superficialmuscular aponeurotic system and platysma during rhytidectomy.

� Extending the deep plane flap inferiorly into the neck and incorporating a platysmal myotomy createsa platysma hammock to define the inferiormandibular contour and support the submandibular gland.

� Deep plane composite flaps of skin, the superficial muscular aponeurotic system, and malar fat canbe repositioned to volumize the midface and gonial angle.

Clin Plastic Surg 45 (2018) 527–554https://doi.org/10.1016/j.cps.2018.06.0070094-1298/18/� 2018 Elsevier Inc. All rights reserved. pl

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when considering the optimal areas for surgicalmanipulation during facial rejuvenation. The lateralSMAS overlying the parotid gland is generally fixedby the parotid cutaneous fascial attachments con-necting it to the underlying parotid gland. We referto this area as the “lateral fixed SMAS.” Release ofthese attachments is required for successful mobi-lization and redraping of the SMAS. SMAS plica-tion or imbrication techniques do not releasethese tissue attachments, so that redraping thejawline and medial facial tissues is more difficult.In contrast, surgical procedures that release thelateral SMAS from its deep attachments allow formore effective redraping of ptotic facial tissues.As the SMAS extends medial to the parotid

gland, it is not firmly adherent. A transition zonecan be seen topographically in the aging facewhere the medial mobile SMAS descends andthe lateral fixed SMAS does not (Fig. 2). The areaof the lateral fixed SMAS involutes, creating a scal-loping or concavity over the gonial angle, and theneck and jawline lie in the same plane with no

distinct mandibular border. As we will discusselsewhere in this article, deep plane faceliftingadds volume and contour to the gonial anglethrough composite flap shifts, improving the defi-nition of the jawline.The deep plane facelift enters the sub-SMAS

plane at a line that traverses from the angle ofthe mandible to the lateral canthus. This approx-imates the transition zone between the fixed andthe mobile SMAS. Traditional low SMAS andhigh lateral SMAS techniques elevate the fixedSMAS that has not descended with age to ac-cess the mobile SMAS that has. The deep planefacelift bypasses lifting the lateral fixed SMASand targets the descended mobile SMAS andmedial soft tissues (Fig. 3). The fixed lateralSMAS is fibrous, adherent, and difficult todissect. The mobile SMAS is areolar in natureand easier to dissect. We believe this variationin SMAS mobility makes facelifting proceduresthat place traction on the medial mobileSMAS instead of the fixed lateral SMAS more

Fig. 1. The superficial muscular aponeurotic system (SMAS) is found in the lateral face overlying the parotidgland, is contiguous with the platysma inferiorly, and terminates at the lateral border of the zygomaticus majormuscle. Medial to this point the malar fat pad overlies the zygomaticus musculature.

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effective in restoring a youthful appearance.This is true for both sub-SMAS and superficialSMAS plication, imbrication, and SMAS-ectomytechniques.

The deep plane facelift also has biomechanicaladvantages when lifting the medial soft tissueptosis of aging compared with lateral SMAS pro-cedures. The sub-SMAS entry point and thus the

Fig. 3. The deep plane facelift enters the sub-superficial muscular aponeurotic system (SMAS) plane at a line thattraverses from the angle of the mandible to the lateral canthus, which exists approximately at transition zonebetween the fixed and mobile SMAS. Traditional low SMAS and high lateral SMAS techniques elevate the fixedSMAS that has not descended to access the medial mobile SMAS that has.

Fig. 2. Preoperative view of a 51-year-old woman demonstrating the “fixed” superficial muscular aponeuroticsystem (SMAS) overlying the lateral face and parotid with a transition zone to the “mobile” SMAS medial tothe parotid where the jowl and lower face descends more readily.

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point of suspension for the deep plane flap isanterior and closer to the ptosis in the midface,jowl, and neck so it allows for more effective lift-ing of facial ptosis. Hooke’s law helps us to un-derstand this concept. Facial tissues haveelasticity and are put on stretch during facelifting,thus acting like a spring. Hooke’s law states thatthe force, or in this case lift, on the spring (theelastic facial tissues) is inversely proportional tothe length of the spring. The deep plane suspen-sion point is one-half the distance from the droop-ing midface and jowl when compared with thesuspension point of lateral SMAS approaches.This means that anteriorly based suspension ex-erts twice the lift on the medial facial tissues(Fig. 4).Another difference between lateral SMAS and

deep plane techniques is that the deep plane face-lift allows for soft tissue elevation of the midface,whereas SMAS flap procedures anatomicallycannot. The SMAS terminates at the lateral borderof the zygomaticus in the midface (as describedelsewhere in this article); therefore, elevation andtraction on this tissue layer cannot effectively exertforce medial to this point (see Fig. 1). The upperand medial midface where the SMAS is absent isoccupied by the cheek fat. Rohrich and Pessa4

divided the cheek fat into the malar and nasolabial

superficial facial fat compartments. The malar fatpad was further subdivided into medial, middle,and lateral anatomic divisions. These fat padsare tethered by the zygomatic cutaneous retainingligaments.5 The nasolabial fat compartment liesimmediately lateral to the nasolabial fold and istethered by fascial attachments to the zygomati-cus major muscle. As aging progresses, the prom-inence over the malar region flattens with descentof the cheek fat. Volume loss becomes noticeablein the upper and lateral midface, and hollowing ofthe lower lid–cheek junction is evident. Thisdescended cheek fat creates a synchronous in-crease and relative widening of the midfacial tis-sues just lateral to the nasolabial folds (seeFig. 7). The advance of these aging changes con-verts the heart-shaped face of youth into aninverted triangle shape. These heterogenouschanges of the different facial fat compartmentshas been confirmed in cadaveric and imagingstudies.6–8

The deep plane rhytidectomy creates a com-posite flap of skin, subcutaneous fat, and malarfat medial to the zygomaticus major muscle afterreleasing the zygomatic cutaneous ligaments.When this composite flap is repositioned vertically,it can be used to volumize the upper midface(Fig. 5). The senior author performed volumetric

Fig. 4. The deep plane suspension point is one-half the distance from the drooping midface and jowl whencomparedwith the suspension point of lateral superficial muscular aponeurotic system approaches. This anteriorlybased suspension can exert more lift on the medial facial tissues. SMAS, superficial muscular aponeurotic system.

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analysis after vertical vector deep plane rhytidec-tomy with a 23-month follow-up and demon-strated that patients gain an average of 3.2 mL ofmidface volume per side. This is the consequenceof full composite flap release, allowing tension-freeredraping of cheek fat compartments.9 There is nostatistical difference between the cheek volumegain from vertical vector deep plane rhytidectomy,and that achieved 16 months after 10 mL ofautologous fat transfer per cheek for midfacialrejuvenation10 (see Fig. 7). When patients haveinsufficient volume reservoir to reposition, volumesupplementation with fat grafting, injectable fillers,or implant placement may be used as an adjunc-tive procedure.

Since the original description of deep plane rhy-tidectomy in 1990 by Sam Hamra,11 the seniorauthor has developed modifications to furtherimprove rejuvenation of the midface, jawline,and neck. This article describes our volumizingextended deep plane facelift (Fig. 6). In brief,skin flap elevation is performed anteriorly up toa preoperatively marked line traveling obliquelyfrom the angle of the mandible to the lateralcanthus. The zygomatic–cutaneous ligamentsare lysed similar to Hamra’s technique, but a

more extensive release of other facial retainingligaments is performed as well. Additional liga-mentous release includes the medial aspects ofthe zygomaticus major, the anterior extensionsof the masseteric cutaneous ligaments, and themandibular cutaneous ligaments. We have alsoextended the deep plane dissection below theangle of the mandible inferiorly. In the neck, theplatysma is elevated from its posterior fascial at-tachments to the sternocleidomastoid muscle toapproximately 5 cm below the inferior body ofthe mandible and anteriorly to the fascia overlyingthe submandibular gland. This maneuver releasesthe cervical retaining ligaments that would other-wise limit platysmal redraping. Incorporating aplatysmal myotomy inferior to the mandibularborder extending medially to the fascia overlyingthe submandibular gland creates a platysmalsling or hammock that supports ptosis of thegland and defines the submandibular contour.This extended sub-SMAS and subplatysmalapproach can also mitigate the need to openthe central neck in patients with mild to moderateneck laxity. Last, we have modified the redrapingand suspension of the composite deep plane flapto volumize the midface and gonial angle, which

Fig. 5. (A) Midface volume augmentation can be achieved by elevating the descended malar fat pads withoutaddition of facial volume. This requires release of the zygomatic cutaneous ligament and vertical vector lifting.(B, D) Preoperative and (C, E) 9-month postoperative views of a 59-year-old woman who underwent an extendeddeep plane facelift. Notice the volumizing of the midface with repositioning of the cheek fat compartments.

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atrophy with age, thus improving cheek andjawline contour.

RELEVANT ANATOMYRetaining Ligaments

Fully understanding the function and anatomy ofthe facial retaining ligaments is paramount to suc-cessful rejuvenation of the aging face. If notreleased, the mobility of facial tissues will begreatly inhibited. With ligamentous release, anyapplied traction to the lateral rhytidectomy flapcan be fully transmitted to the medial facial soft tis-sues, allowing a natural and complete redraping.These concepts can be viewed as a natural exten-sion to the same reconstructive principles usedwhen soft tissues surrounding cutaneous defectsare widely undermined and mobilized during localflap closure. In such cases, it is well-known thatwide release allows for successful tissue redrapingand a durable, tension-free closure.Retaining ligaments are strong, fibrous attach-

ments that secure defined dermal regions todeeper structures. They are present both within

the face and cervical regions (Fig. 7). Two typesof ligaments have been described. Osseocutane-ous ligaments run from the periosteum to thedermis. These include the zygomatic and mandib-ular ligaments. The second type of ligament isformed from a coalescence of superficial anddeep facial fascia. Examples of this type of liga-ment are the parotid cutaneous and massetericcutaneous ligaments.12

The zygomatic retaining ligaments originatefrom the periosteum of the zygoma body andextend through the malar fat pad and insertinto the overlying dermis. The zygomatic retain-ing ligaments fix the aging midface and cheekfat. Biomechanical studies have shown that thezygomaticocutaneous ligament is the strongestof all of the facial retaining ligaments, elongatingby a mere 9 mm.13 Additional tendinous attach-ments run from the zygomaticus major and mi-nor through the malar fat to the skin, reachingthe nasolabial fold overlying the maxilla medially.This is called the premaxillary space.14

The mandibular cutaneous ligaments originatefrom the periosteum of the parasymphyseal

Fig. 6. Planes of dissection of the deep plane facelift, with a deep plane entry point from the angle of themandible to the lateral canthus, and our modification extending the deep plane for 5 cm below the angle ofthe mandible with a platysma myotomy to the submandibular gland.

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region of the mandible. They similarly traversesuperficially and insert into the overlying dermis.The mandibular retaining ligaments limitthe mobility of the skin and soft tissue aroundthe prejowl sulcus. By tethering the skin at themandibular border, it prevents anterior submen-tal neck skin redraping during rhytidectomy.The further posterior the ligament is displacedfrom the symphysis the greater tetheringeffect it has in the neck. In our study of 108 pa-tients, we found the average tethering point tobe 5 cm lateral to the symphysis. This meansthe surgeon would note a restriction of anteriorcervical skin redraping starting approximately5 cm posterior to the pogonion (Jacono AA:Limitation of neck redraping due to mandibularligament tethering, personal communication,2013).

Masseteric cutaneous ligaments lie along theanterior border of the masseter muscle. This liga-mentous confluence acts to tether the jowl poste-riorly. Complete ligamentous release requires

elevation of the SMAS to the anterior border ofthe masseter.12 The parotidocutaneous ligamentlies along the parotid gland, and are bypassedas the sub-SMAS dissection in deep plane sur-gery begins anterior to their point oftermination.15

The cervical retaining ligaments of the neck arereproducibly found along the posterior border ofthe platysma at its junction with the sternocleido-mastoid muscle, along the anterior inferior portionof the parotid gland, and along the posterior bodyof the mandible.16,17 They tether the platysma tothe deeper cervical fascia along the angle of themandible and along the anterior border of theSCM. Just like facial ligaments, the cervical retain-ing ligaments restrict the surgeon’s ability to mobi-lize and redrape the platysma if not released.Extending the deep plane subplatysmal dissectioninferiorly into the neck requires a lateral platysmaldissection to release the cervical retaining liga-ments.18,19 We have performed anatomic studiesthat demonstrated that the cervical retaining

Fig. 7. Ligamentous attachments released in the extended deep plane face lift include the zygomatic cutaneousligaments, the maxillary ligaments, the anterior extensions of the masseteric cutaneous ligaments, the mandib-ular cutaneous ligaments, and the cervical retaining ligaments.

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ligaments extend for 1.5 cm medial to the anteriorborder of the SCM.20 Complete redraping of theplatysma thus requires extended platysma flapelevation past this point.

SURGICAL TECHNIQUEPreoperative Marking

The patient is positioned upright to be marked pre-operatively (Fig. 8). The rhytidectomy incision ismarked as well as the path of the temporal branchof the facial nerve, and the deep plane entry point.The deep plane entry point is marked as a lineextending from the angle of the mandible to thelateral canthus. This places the area of SMASmanipulation anterior to the fixed lateral SMAS. Ahorizontal line is drawn across the neck at the levelof the cricoid to mark the minimal inferior extent ofneck skin elevation. We council male patientsabout the potential for transposition of beardedskin into the ear canal with a retrotragal incisionand discuss a preauricular incision as an option.The patient is allowed to decide on the approach.In our practice, approximately 75% of men choosethe retrotragal approach for improved incisioncamouflage.

Incision and Skin Flap Elevation

Skin incision is initiated with a No. 10 scalpel cut-ting perpendicular to the skin at the dense

hairline of the temporal hair tuft. We use a tem-poral hair tuft–sparing incision because thedeep plane technique causes large flap shiftsthat would result in removing the temporal hairwhen skin is removed at the end of the surgery.The temporal and occipital hairline portions ofthe incision can be extended during the opera-tion if further skin redraping is needed. When abeveled trichophytic incision was used, thelong-term outcome commonly resulted in adepressed incision in a significant percentageof cases. We believe this occurs because theskin of the anterior temporal region is thin andthe skived edge of the beveled incision tendsto become devitalized and heal in a contractedfashion. This is different from the thicker anteriorforehead/scalp skin in the area of the frontal hair-line, where trichophytic incisions were firstdescribed. We have noted temporal scars thatare barely perceptible with this modification(Fig. 9).Coursing inferiorly from the temporal region,

the incision should not be placed at the anterioredge of the helical crus cartilage because it canmake the root of the helix seem to be unnaturallywide. It should be placed at the natural highlight,which reflects the apparent width of the helicalcrus. It should then traverse along the posterioredge of the tragus, but not on its inner surfaceas this can create an unnatural folding of thecheek skin that blunts the tragus and can be atell-tale sign of a facelift incision. A small stepin the incision is placed at the inferior tragus topreserve the natural depression at the intertragicincisure. Around the earlobe, the incision shouldcontinue 2 mm inferior to the lobule cheek junc-tion to preserve the natural sulcus between thelobe and the cheek. Posteriorly, the incisionshould continue a few millimeters onto the pos-terior conchal cartilage rather than directly inthe postauricular crease. This step helps to mini-mize later inferior descent of the posterior auric-ular scar into a more visible location with age. Inpatients with less neck laxity, the incision endshere. If the surgeon is uncertain of the amountof neck skin that will need excision, the incisioncan always be extended to remove redundancy.In cases of more significant neck skin excess,the incision is transitioned at the level of thetriangular fossa down the anterior aspect of theoccipital hairline posteroinferiorly. In the past,we used a high transverse incision that was hid-den in the occipital hair. This incision requiresthat the neck skin flap be shifted anteriorly andvertically to prevent hairline margin step offs,which limits the amount of redundant neck skinthat can be removed.

Fig. 8. Important landmarks drawn preoperativelyinclude the trajectory of the temporal branch of thefacial nerve, the deep plane entry point, incision lines,and inferior extent of neck skin elevation.

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Fig. 9. Postoperative preauricular facelift incision. (A) Preoperative and (B) 12 months postoperatively. Postoper-ative views of a 53-year-old woman who underwent an extended deep plane facelift. (C) Notice well-healed tem-poral scar and well-camouflaged retrotragal incision with preservation of infratragal hollow.

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After the initial rhytidectomy incision is made,the facial subcutaneous flap is elevated witha No. 10 scalpel. The skin flap is elevatedanteriorly approximately 2 cm to allow forplacement of an Anderson multiple prongretractor. The retractor is used to place superiorand lateral tension on the flap. Direct counter-tension is placed by an assistant manuallyretracting the skin in the opposite directionand the flap is backlit to visualize the subdermalplexus (Fig. 10). Flap elevation continues withfacelift scissors, tips pointed upward, makingsmall, forward-snipping motions to create aneven-thickness flap. The intensity of the transil-luminated light gives the surgeon the ability togauge the thickness of the flap and create a uni-form depth. Subcutaneous elevation in thecheek ends approximately 2 to 4 mm beyondthe marked line of the deep plane entry point(Fig. 11). The deep plane facelift approachposes no risk to the frontal branch becausethe dissection is superficial in the subcutaneousplane where the frontal branch exists, and thesub-SMAS dissection is begun at the deepplane entry point, which is 2 cm anterior andparallel to the course of the frontal branch ofthe facial nerve.The postauricular skin is then dissected in a

similar fashion and connected to the facial dissec-tion. Once dissection has reached the anteriorborder of the SCM, the inferior and medial subcu-taneous/supraplatysmal dissection in the neck isaccomplished with a lighted retractor to providetension and facelift scissors using a vertical bluntspreading. Dissecting on top of the supraplatysmalfascia during the medial neck skin elevation pre-serves a blanket of fat on the skin flap that preventsirregularities and adhesions between the deepdermis of the skin and the platysma postoperatively.

This dissection is continued to the midline and infe-riorly to just below the level of the cricoid (Fig. 12).Attention is directed to the mandibular cuta-

neous ligaments. The mandibular cutaneous liga-ments are released using the same backlit skin-under tension method as the rest of the skin flap,releasing the ligaments in a subcutaneous plane.In cases with more fibrous and dense ligaments,dissection can be aided through the submentalincision and a sharp curved iris sharp scissor canbe used instead of facelifting scissors (Fig. 13).

Deep Plane Dissection: Release of theZygomatic–Cutaneous Ligament, ZygomaticusMajor Muscle Fibrous Attachments, andMasseteric Cutaneous Ligaments

An Anderson 5-prong retractor is placed at the ante-rior extent of the skin dissection parallel to the deepplane entry point line. The flap is held under verticaltension away from the body and a No. 10 scalpel is

Fig. 10. Elevation of the subcutaneous flap to thedeep plane entry point is performed with a faceliftscissor with the flap back lit with an operating roomlight to visualize the subdermal plexus and maintainuniform flap thickness.

Fig. 11. The preauricular subcutaneous flap ends atthe marked line of the deep plane entry point.

Fig. 12. Neck flap subcutaneous dissection is continuedto the midline using a longer lighted retractor and longfacelift scissors.

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used to incise the SMAS layer and expose the deepplane (Fig. 14). The incision extends from themandible to the to the orbital rim near the lateralcanthus. A lighted retractor is again used to createvertical tension away from the body and verticalblunt dissection with facelift scissors is performedto elevate the composite flap of skin and SMAS offthe parotid–masseteric fascia. The masseteric cuta-neous ligaments are released, allowing for morecomplete repositioning of the jowl (Fig. 15). Com-plete ligamentous release requires elevation of thecomposite flap to the anterior border of themasseter.12 Another dissection endpoint is thefacial artery, which can be palpated and visualizedin the sub-SMAS plane. Elevation of this flapcontinues superiorly until resistance is reached atthe zygomatic osteocutaneous ligament. Blunt

dissection through the inferior part of the deep planeflap is continued under the platysma below themandibular border and onto the neck to facilitatelater release of the platysma from the sternocleido-mastoid muscle.

The zygomatic ligaments are isolated by bluntdissection of the superior extent of the deepplane entry point in the prezygomatic space.14

Here, the dissection plane lies superficial to theorbicularis oculi muscle. Once the lateral borderof the orbicularis is identified, the prezygomaticspace can be easily dissected with blunt fingerdissection. This dissection is carried mediallyinto the premaxillary space, ending at the nasalfacial crease. This technique was originallydescribed as the FAME or finger-assisted malarelevation by Aston21–24 (Fig. 16). BecauseSMAS is not present medial to the zygomaticusmajor, the composite flap in this area iscomposed of skin and the malar fat pad.

Fig. 13. Release of the mandibular ligaments requiresdissection to the posterior edge of the tethering pointand inferiorly to the lower edge of the mandible as ittransitions to neck.

Fig. 14. (A) An Anderson 5-prong retractor is placed at the anterior extent of the skin dissection parallel to thedeep plane entry point line. (B) With vertical tension on the retractor, a No. 10 scalpel is used to make the incisioninto the deep plane.

Fig. 15. The sub-superficial muscular aponeurotic sys-tem dissection continues anteriorly with verticalspreading motion with a facelift scissor until themasseteric cutaneous ligaments are released to theanterior border of the masseter.

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At this point, the zygomatic osteocutaneousligaments have been isolated between the upperand lower composite deep plane flaps. These lig-aments tether the SMAS/platysma complex tothe malar bone and must be released to accom-plish vertical elevation of the composite flap.Sharp dissection of the ligaments is initiatedwith a No. 10 scalpel staying superficial to thezygomaticus musculature (Fig. 17). Staying

superficial to the zygomaticus protects the facialnerve branches, which innervate the zygomati-cus muscle from its deep surface. After sharprelease of the dense ligaments, blunt dissectioncontinues along the plane of the zygomaticusmajor and minor until the premaxillary spaceand nasolabial fold is reached (Fig. 18). A densemaxillary ligament at the inferior border of thepremaxillary space is bluntly dissected to com-plete midface release.14

Release of the Cervical Retaining Ligaments

With the deep plane now free, the only remainingpoint that tethers the SMAS–platysma complexfrom moving vertically is the cervical retaining lig-aments. The deep plane flap in the neck ismarked from the gonial angle to the anteriorborder of the sternocleidomastoid muscleextending 5 cm inferiorly into the neck. A lightedretractor provides countertraction and the pla-tysma muscle is partially incised. After incision,the remaining fibrous and ligamentous attach-ments at the anterior border of the sternocleido-mastoid muscle are released with gentle, bluntscissor dissection. This dissection continues

Fig. 16. Elevation of the superior aspect of the deep plane pocket. (A) Blunt dissection at the superior extent ofthe deep plane entry point, creating a plane superficial to the orbicularis oculi muscle (B). (C) Blunt finger dissec-tion medially to free it to the deep plane to the nasal facial crease. Note the circular hashed marking that iden-tifies the location of the zygomatic ligaments.

Fig. 17. Release of the deep plane flap with sharpdissection of the zygomatic ligaments using a No. 10scalpel cutting from superior to inferior and stayingsuperficial to the zygomaticus musculature.

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anteriorly and connects with the subplatysmaldissection plane that was previously created dur-ing the facial dissection. The anterior limit of theplatysma flap is the anterior border of the sub-mandibular gland so that the platysma flap cansuspend gland ptosis (Fig. 19).

The dissection plane immediately below theplatysma ensures that the marginal mandibularand cervical branches of the facial nerve downremain deep, on the superficial cervical fascia.

Dissection immediately under the platysma inthe neck below the gonial angle is a safe planeprotecting the marginal branch of the facialnerve, analogous to dissection just underneaththe SMAS in the cheek is a safe plane protectingthe facial nerves. The nerves above the gonialangle are in the parotidomasseteric fascia andbelow it in the superficial cervical fascia. Theselayers are contiguous. The marginal branchwould be at risk if dissection under the SMAS

Fig. 18. (A) Deep plane flap is released through the zygomatic ligaments and (B) elevated to the nasolabial fold.

Fig. 19. Release of the cervical retaining ligaments. (A) Surgical marking of the lateral platysmal border at itsconnection to the sternocleidomastoid muscle extending 5 cm below the angle of the mandible. (B) A No. 15scalpel is used to make a broad and gentle incision until a lip of tissue is obtained, the edge grasped and sharpdissection within the sternocleidomastoid muscle fascia is continued for approximately 1 cm, (C) Subplatysmalflap freed after bluntly dissect through the ligaments 3 cm anterior to the sharply elevated flap.

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and platysma is continued medial to the facial ar-tery where the nerves become more superficial.Therefore, dissection in this region should beavoided.

Deep Plane Flap Suspension

Because the skin flap was raised slightly beyondthe deep plane entry point in the face, this cuff ofSMAS tissue is used for suture suspension. Fiveto 7 suspension sutures are placed (the author’spreference is 4-0 nylon with PS-2 needle in mostcases). The angle of flap suspension transitionsfrom vertically dominant at the mandibular angleto horizontally dominant near the orbit (Fig. 20).This maximizes elevation of the cheek fat padswhile preventing distortion of tissues in the templeregion and lateral to the eye. The vector of lift forthe composite flap in deep plane rhytidectomy isvertical oblique. The individual’s anatomy dictatesthe exact angle. In a study of more than 300

patients, the average vector approached 60� rela-tive to the Frankfort horizontal plane25 (Fig. 21).Suture suspension begins with a half-mattress su-ture connecting the SMAS cuff at the deep planeentry point to the parotid masseteric fascia in thepreauricular region for suspension of the inferiorportion of the flap.It is important to note that redraping of the

inferior deep plane composite flap createimproved mandibular contour. With age, thearea over the lateral fixed SMAS and gonialangle becomes concave, blunting the jawlineas it transitions into the neck. The inferior partof the composite skin and SMAS deep planeflap is fixated at the level of the gonial angle.This volumizes the gonial angle and createsa more distinct mandibular/jawline contour(Fig. 22).The superior portions of the flap in the upper

cheek are suspended to the deep temporal fas-cia. Importantly, the point of flap suspension forthe upper flap is to the deep temporal fascia2 cm above the zygomatic arch, similar to thehigh and lateral SMAS facelift. Repositioningthe ptotic midface revolumizes the upper cheekover the zygoma. Volumetric analysis with23 months of follow-up has shown that this sus-pension technique give patients an average gainof 3.2 mL of volume in each hemi midface9 (Figs.23 and 24).

Lateral Platymsa Suspension in the Neck andSkin Closure

After resuspension of the composite flap in theface is finished, attention is directed to redrapingof the cervical platysma. A horizontal myotomy ofthe platysma is performed parallel to the inferiormargin of the mandible for approximately 4 cm,

Fig. 20. The deep plane flap is typically sutured at 5 to7 nearly equidistant points along the cuff formed atthe deep plane entry point to the preauricular anddeep temporal fascia.

Fig. 21. (A) The flap is suspended vertically at an angle that maximizes elevation of the cheek fat pads and rev-olumizes the midface. (B) Suture suspension along vertically oblique vector of 60�.

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ending at the area over the submandibular gland.The inferior platysmal tab is anchored to themastoid fascia with a 3-0 nylon suture and posi-tioned just below the margin of the mandible(Fig. 25). The vector of pull runs along the

submandibular region and away from the cervi-comental angle. This platysmal flap placesits maximal tension at the most anterior extentof the myotomy, allowing for support of thesubmandibular region, elevating any ptotic

Fig. 22. (A, B) The inferior part of the composite skin and superficial muscular aponeurotic system (SMAS)deep plane flap is fixated at the level of the gonial angle. This volumizes the gonial angle and createsa more distinct mandibular/jawline contour. Preoperative view of (C) a 56-year-old woman, (E) a57-year-old woman, and (G) a 58-year-old woman. (D, F, H) The same patients at 12 months postoperativeafter volumizing extended deep plane rhytidectomy with composite flap repositioning to augment thegonial angle.

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Fig. 23. (A, C) Preoperative and (B, D) 9 months postoperative views of a 57-year-old woman who underwent anextended deep plane facelift with zygomatic ligament. Notice the volumizing of the midface with repositioningof the cheek fat compartments.

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Fig. 24. (A, C) Preoperative and (B, D) 15 months postoperative views of a 62-year-old woman who underwent anextended deep plane facelift with zygomatic ligament. Notice the volumizing of the midface with repositioningof the cheek fat compartments.

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submandibular tissues, while concomitantlyincreasing a hollow below the angle of themandible that exists in youth. Interestingly, thisalso places more traction on the platysma ante-riorly and can help to smooth out platysmalbands, avoiding the need to open the neck(Figs. 26–28). Additional sutures are used toredrape the incised platysmal edge over the ster-nocleidomastoid muscle. A Jackson-Pratt drainis placed in the hairline, and positioned in thelower neck until the next morning.After resuspension of the face and neck,

attention is turned to redraping of the skin. Thefacial skin is suspended in the same plane asthe composite flap. The majority of the skin isremoved vertically in the temporal region(Fig. 29). Because the cervical skin has beenlifted off the platysma, redraping does not needto equate the platysmal lift vector. Adequateelevation of the temporal skin in the subcutane-ous plane avoids bunching. In patients withmore significant laxity, the temporal incisionmust be carried along the hairline superior to

the lateral brow to avoid a dog ear deformity.Deep, everting 4-0 Vicryl sutures are placedalong the temporal incision prevent depressionand spreading of the scar over time. Skin closureis completed with everting 5-0 nylon verticalmattress sutures. The remainder of the incisionis closed with 5-0 nylon sutures anteriorly, 5-0 nylon sutures behind the ear, and 4-0 nylon su-tures in the occipital hairline (Fig. 30). The major-ity of anterior sutures are removed after 4 to5 days.We perform subcutaneous liposuction in the

neck in less than 10% of our patients, and onlywhen they have significant supraplatysmal fatexcess, which can be grasped and clearly iden-tified before injection. In general, we prefer toleave the natural blanket of fat between theskin and platysma to avoid forming depressionsfrom adhesions and retraction. When performingsubmental liposuction we use modern tech-niques that mitigate the chance of commonlynoted irregularities.26–35 In general, we havefound that elevating the neck skin flap before

Fig. 25. (A) Horizontal myotomy of the platysma performed parallel to the inferior margin of the mandible forapproximately 4 cm ending at the area over the submandibular gland. (B) Intraoperative view of horizontal my-otomy of the platysma performed parallel to the inferior margin of the mandible for approximately 4 cm endingat the area over the submandibular gland. (C) The inferior platysmal tab is anchored to the mastoid fascia with a3-0 nylon suture and positioned just below the margin of the mandible creating a platysma hammock that ele-vates the ptotic submandibular gland. Mandibular contour. (D) Note contour improvement of jawline and upperneck with tension placed on platysmal hammock. The circle marked on the skin is the location of the submandib-ular gland.

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Fig. 26. (A, C) Preoperative and (B, D) 12 months postoperative views of a 51-year-old woman who underwent anextended deep plane facelift. Note improvement in anterior neck cording without opening the neck.

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Fig. 27. (A, C) Preoperative and (B, D) 12 months postoperative views of a 61-year-old woman who underwent anextended deep plane facelift with platysma hammock suspension of the submandibular gland and improvementin anterior neck cording without opening the neck.

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liposuction controls the amount of fat on theneck skin and decreases the risk of postopera-tive topographic irregularities. After flap elevation

we use a 3-mm flat-tipped liposuction cannula tothen remove supraplatysmal fat and sculpt theneck (Fig. 31).

Fig. 28. (A, C) Preoperative and (B, D) 12 months postoperative views of a 58-year-old woman who underwent anextended deep plane facelift with platysma hammock suspension of the submandibular gland and improvementin anterior neck cording without opening the neck.

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Adjunctive Submental Procedures andPlatysmaplasty

Our main indications for rhytidectomy withoutopening the neck is if the submental platysmaland skin laxity is corrected when the surgeonplaces 3 fingers at the deep plane entry point,a line from the angle of the mandible to thelateral canthus, on both sides of the face andmoves the skin vertically. If the patient still hassignificant neck redundancy with this maneuverand platysmal cording exists, then a midline pla-tysmaplasty is indicated in addition to the verti-cal neck lift. We use 3 other indications for amidline approach. If widely separated midlineplatysma bands exist, midline plication is usedto bridge their dehiscence. This is described asa DeCastro type III decussation pattern.36 Addi-tionally, a midline approach is used when sub-platysmal surgery, such as subplatysmal fatremoval, is performed to prevent cobra neck

deformity occurring postoperatively. Last,midline plication is indicated when intraopera-tively the midline platysmal redundancy remainsafter the lateral platysmal lift is performed bilater-ally. If it is determined preoperatively that the pa-tient will require anterior platysmaplasty, this isperformed before rhytidectomy. Increasing thenumber of procedures performed in the submen-tum increases the chances of irregularities, andeach maneuver must be performed preciselyand in a metered fashion.A small submental incision is made and the

submental skin is dissection with a curved irisscissor. Once an entry skin flap has beenmade, a skin hook is used to place the cervicalskin under traction, while subcutaneous flapelevation continues using a blunt curved scissor(Metzenbaum).At this point, the medial edges of each side of

the platysma muscle are identified. The subplatys-mal plane is extended laterally to the anteriorborder of the submandibular gland. The intrapla-tysmal fat is dissected away from the platysmalborders using blunt dissection and bipolar cauteryfor hemostasis. This midline mobilization of theplatysma is extended approximately to the inferiorborder of the cricoid. The interplatysmal and sub-platysmal fat is then removed from the submentalarea using suction monopolar cautery. Once thefat is removed, the subplatysmal flap is extendedlaterally.The anterior belly of the digastric muscle is

identified, and is sculpted with monopolarsuction cautery if it contributes to submentalfullness as identified on preoperative photo-graphs. The neck is irrigated, and the midlineplatysmaplasty is closed using interrupted,buried 4-0 Vicryl sutures. There are key suturesused when closing the midline platysma. The first

Fig. 29. The majority of the skin redundancy isremoved vertically in the temporal region.

Fig. 30. (A) Preauricular and (B) postauricular skin closure.

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suture is placed at the cervicomental region.Here, the platysmal edges are sutured to themidline hyoid fascia to prevent separation anda midline banding after healing.37 Additionalinterrupted 3-0 Vicryl sutures similarly adherethe platysmal edges to the deep submental tis-sues along the length from the chin to the hyoidto aid in cervical definition. The platysmal corsetcontinues inferiorly to the level of the cricoid(Figs. 32–34).

Special Considerations in Deep PlaneRhytidectomy

EfficacyThere is a paucity of data comparing efficacy ofrhytidectomy by technique. Short-term follow-uphas shown higher efficacy in techniques usingmore aggressive SMAS manipulation, boastingfewer secondary procedures and happier pa-tients.38 The need for tuck up varies widely amongrhytidectomy techniques and surgeons. SMASplication and imbrication techniques have beenshown to carry the highest tuck up rates of up to21%39 and up to 50% at 2 years.40 More extensiveskin flaps with extended SMAS dissections have alower tuck up rate of 11%.41 The deep plane

rhytidectomy reproducibly carries substantiallylowered tuck up rates of 3% to 4%, which is statis-tically significant.18,41

Studies on medium-term efficacy show thatless invasive SMAS approaches have a greaterrecurrence of neck laxity than jowl reformation.38

There are few long-term follow-up data availablefor review. Patients presented for secondaryfacelifts after primary SMAS plication rhytidec-tomy on average 9 years later.42 Secondaryfacelifts were sought after primary SMAS flaprhytidectomy on average 11.9 years later, sug-gesting this is a slightly more durable procedure;however, the data remain too limited to drawconclusions and the significance of this informa-tion is unclear.43

ComplicationsIt is important to clarify that more aggressivedissection with deep plane techniques doesnot portend an increased risk to the patient.The rates of facial nerve damage and hematomain deep plane rhytidectomy has been shown tobe equal to those of less invasive tech-niques.18,41 Our incidence of temporary facialnerve injury with an extended deep planeapproach is 1.2% in a prior study reviewing

Fig. 31. (A) Preoperative and (B) 12 months postoperative views of a 59-year-old woman who underwent a modi-fied, extended deep plane facelift without midline platysmaplasty but requiring supraplatysmal liposuction afterskin flap elevation.

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Fig. 32. (A, C) Preoperative and (B, D) postoperative views of a 62-year-old woman with excessive platysmalredundancy. She required a concomitant midline corset platysmaplasty suspended to the hyoid fascia with anextended deep plane facelift.

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323 patients who underwent this technique withthe primary author,44 and has remained stableon follow-up review of more than 800 cases.This temporary facial nerve injury rate is thesame as less invasive SMAS plicating and

suturing techniques that can cause temporarytraction injury.45

Deep plane surgery bears an improved risk pro-file in some aspects when compared with thetraditional less extensive surgeries. It is associated

Fig. 33. (A, C) Preoperative and (B, D) 12 months postoperative views of a 56-year-old woman with excessive pla-tysmal redundancy. She required a concomitant midline corset platysmaplasty suspended to the hyoid fascia withan extended deep plane facelift.

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Fig. 34. (A, C) Preoperative and (B, D) 12 months postoperative views of a 70-year-old woman with poor submen-tal contour requiring concomitant subplatysmal lipectomy, digastric reduction and midline corset platysmaplastysuspended to the hyoid fascia with an extended deep plane facelift.

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with lower rates of skin flap sloughing and need fortuck up procedures.18,41

SUMMARY

The volumizing extended deep plane rhytidectomyis a safe procedure with superior outcomes infacial rejuvenation. A comprehensive understand-ing of the facial anatomy and pathophysiology ofaging is imperative to incorporate this proceduresuccessfully. The extended deep plane facelift in-corporates additional ligamentous release of theface and neck to create durable redraping offace and neck ptosis redraping. This includes thezygomatic cutaneous, masseteric cutaneous,mandibular cutaneous, and cervical retaining liga-ments. Deep plane dissection creates compositeflaps that can be redraped to volumize the midfaceand gonial angle along the jawline, thus improvingcheek and jawline contour.

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